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Effective Health Care Program

Noninvasive, Nonpharmacological Treatment for Chronic Pain: A Systematic Review

Systematic Review Draft

Open for comment through Dec 26, 2017

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Purpose of Review

To assess evidence on noninvasive, nonpharmacological treatments for common chronic pain conditions, focusing on whether improvements are seen for at least one month post-intervention.

Key Messages

  • A number of nonpharmacological interventions may improve function or pain outcomes 1 month to 1 year after the completion of therapy; evidence for some treatments and conditions is limited.
  • Exercise, acupuncture, multidisciplinary rehabilitation, mind-body and mindfulness practices and psychological therapies such as cognitive-behavioral therapy may improve function or pain outcomes for specific chronic pain conditions.
  • There was no evidence suggesting serious harms from any of the interventions studied, although data on harms were limited.
  • Additional comparative evidence with data on the sustainability of effects on function and pain outcomes is particularly needed for chronic tension headache, as well as for osteoarthritis, chronic neck pain, and fibromyalgia.

Structured Abstract

Objectives. To assess the effectiveness of noninvasive, nonpharmacological treatment for selected chronic pain conditions, particularly as alternatives to opioids and other pharmacological treatments, with a focus on evaluating which interventions provide improved function and pain outcomes for at least 1 month post-intervention.

Data sources. Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, no restriction on publication date), reference lists, and ClinicalTrials.gov.

Review methods. Using predefined criteria, we selected randomized controlled trials of noninvasive, nonpharmacological treatments for five common chronic pain conditions (low back pain, neck pain, osteoarthritis of the knee, hip or hand, fibromyalgia, and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. The quality of included studies was assessed, data were extracted, and results were summarized quantitatively and qualitatively. Only trials reporting results for at least 1 month post-intervention were included. We focused on evaluating the persistence of effects for therapies beyond the course of treatment at short-term followup (1 to 6 months following completion of treatment), intermediate-term followup (6 to 12 months), and long- term followup (≥12 months).

Results. 205 publications (192 trials) were included in the review. Many included trials were small and the majority of patients were female. In general, there was little followup beyond 1 year after completion of treatment. Most trials enrolled patients who experienced a moderate pain intensity (e.g., >5 on a 0 to 10 point numeric rating scale for pain) and duration of symptoms ranging from 3 months to >15 years.

 Chronic low back pain: Function improved slightly in the short term with massage, yoga, and psychological therapies (Strength of evidence [SOE]: Moderate) and with exercise, acupuncture, low-level laser therapy, mindfulness-based stress reduction (MBSR), spinal manipulation, and multidisciplinary rehabilitation (SOE: Low), compared with usual care or inactive controls. Effects on function continued into the intermediate term for yoga, MBSR, spinal manipulation, multidisciplinary rehabilitation (SOE: Low), and psychological therapies (SOE: Moderate). Psychological therapies, were associated with slightly greater improvement than usual care or an attention control on both function and pain at short-term, intermediate-term, and long-term followup (SOE: Moderate). Improvements in pain persisted into the intermediate term for exercise, massage and yoga (moderate effect, SOE: Low), MBSR (small effect, SOE: Low) as well as spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects, SOE: Moderate). For acupuncture there was no difference in pain at intermediate term, but a slight improvement at long-term (SOE: Low). Effects on function were generally smaller than effects on pain. Multidisciplinary rehabilitation slightly improved pain at short and intermediate terms compared with exercise (SOE: Moderate). High-intensity multidisciplinary rehabilitation (≥20 hours/week or >80 hours total) was not clearly better than non-high-intensity programs.

 Chronic neck pain: In the short- and intermediate-term studies, acupuncture and Alexander Technique slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (SOE: Low), but no improvement in pain was seen at any time frame (SOE: Low). Short-term, moderate effects on function and pain were seen for low-level laser therapy (SOE: Moderate).

 Osteoarthritis: For knee osteoarthritis, only exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control or sham procedure (SOE: Moderate for exercise, Low for ultrasound). Effects were sustained into the intermediate term only for exercise (SOE: Low), which was also associated moderate improvement in pain (SOE: Low). Long-term, the small improvement in function seen with exercise was sustained, but there was no clear effect on pain (SOE: Low). Evidence was sparse on interventions for hip and hand osteoarthritis. Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care in the short term (SOE: Low). The effect on function was sustained intermediate term (SOE: Low).

 Fibromyalgia: Function improved slightly in the short term with cognitive behavioral therapy (CBT) and tai chi and qigong mind-body practices (SOE: Low) and with acupuncture (SOE: Moderate). Improvements in pain were seen in the short term with exercise (SOE: Moderate) and mind body practices (SOE: Low). Small functional improvement continued into the intermediate term for acupuncture and cognitive behavioral therapy CBT (SOE: Low) and was seen for myofascial release massage and multidisciplinary rehabilitation (SOE: Low). Long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: Low for all) and no clear impact on pain for exercise (SOE: Moderate) or multidisciplinary rehabilitation was seen (SOE: Low).

 Chronic tension headache: Evidence was sparse and the majority of trials were of poor quality.

There was no evidence suggesting increased risk for serious treatment-related harms for any of the interventions, although data on harms were limited.

Conclusions. A number of nonpharmacological interventions can provide beneficial effects on function and/or pain that are durable 1 month to 1 year after the completion of therapy. Exercise, multidisciplinary rehabilitation, acupuncture, and mind-body and mindfulness practices may slightly to moderately improve function and pain across multiple chronic pain conditions. Our findings provide some support for clinical strategies that focus on use of nonpharmacological therapies as preferred interventions for chronic pain. Additional comparative research on sustainability of effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.